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Central Lakes College
Upward Bound
Program Application
Name: ____________ School: _______Grade:___
Collaboration between Central Lakes College and the US Department of
Education
Central Lakes College Upward Bound
Central Lakes College
501 West College Drive
Brainerd, MN 56401
(218) 855.8011
Directions: Do not write below these directions. Students- please fill out pages 3 and 4. Then
give it to your Parent/Guardian to fill out pages 5-7. When finished, please return promptly to
your Guidance Counselor who will fill in page 8. If your school does not have a Guidance
Counselor, please turn the application into your School Principal. If you have any questions,
please contact Upward Bound at the above numbers. Please have this completed and turned into
your guidance counselor / principal as soon as possible or by ________________
________________________________________________________________________
Professional Education School Staff Comments
(For Upward Bound Staff Use Only)
______________________________________________
______________________________________________
______________________________________________
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WHAT IS TRIO?
TRIO is Educational Opportunity for Low-Income and Disabled Americans.
Our nation has asserted a commitment to providing educational opportunity for all Americans
regardless of race, ethnic background or economic circumstance.
Upward Bound is one part of the family of programs that Congress created in support of this
commitment. Congress established a series of programs to help low-income Americans enter
college, graduate and move on to participate more fully in America’s economic and social life.
These Programs are funded under Title IV of Higher Education Act of 1965 and are referred to
as the TRIO Programs (initially just three programs). While student financial aid programs help
students overcome financial barriers to higher education, TRIO programs help students
overcome class, social and cultural barriers to higher education.
Who Is Served
As mandated by Congress, two-thirds of the students served must come from families that meet
federal income requirements, and where neither parent graduated from a four year college. More
than 2,600 TRIO programs serve students in grades six through 12. Thirty-seven percent of
TRIO students are white, 35% are African-Americans, 19% are Hispanics, 4% are Native
Americans, 4% are Asian-Americans, and 1% are listed as “Other,” including multiracial
students. Twenty-two thousand students with disabilities and more than 25,000 U.S. veterans are
currently enrolled in TRIO programs as well.
How It Works
Over 1,000 colleges, universities, community colleges, and agencies now offer TRIO programs
in America. TRIO funds are distributed to institutions through competitive grants.
Evidence of Achievement
Students in the Upward Bound program are four times more likely to earn an undergraduate
degree than those students from similar backgrounds who did not participate in TRIO; nearly 20
percent of all Black and Hispanic freshmen who entered college in 1981 receive assistance
through the TRIO Talent Search or EOC programs; students in the TRIO Student Support
Services program are more than twice as likely to remain in college than those students from
similar backgrounds who did not participate in the program.
Taken from: http://www.trioprograms.org/abouttrio.html
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Central Lakes College Upward Bound Student Application
Student Information
This information is compiled to report to the US Department of Education.
Student Information
Student’s Name_______________________________________Grade:_________________________
Mailing Address_____________________________________________________________________
City, State, Zip Code_____________________________________ Email________________________
Phone Number_________________________ Social Security #____________________
If you do not have a Social Security Number, please provide a copy of your green card.
Is the student a US Citizen:
Yes __
Date of Birth_________________
No __
Age_____________ Male_______ Female
What would the student consider their race or ethnicity to be? (Please mark which apply)
__ Caucasian
__ Asian
__ Black/African American
__ American Indian or Alaskan Native
__ Native Hawaiian/Other Pacific Islander
__ Hispanic/Latino
Does the student have any disabilities?
__
Learning
__
Physical
Other (please specify)______________________________
Does the student have a court appointed guardian?
Yes __ No __
Please provide name(s) of parent(s)
or guardian(s) with whom the student lives
______________________________________________________________________
Student’s place of employment (if employed)__________________ Phone ________________
Educational Information (to be completed by student)
Does the student work with a Special Education teacher? Yes__________ No_______________
If yes, teacher’s name______________________________________________________
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Central Lakes College Upward Bound
STUDENT INFORMATION
What are five activities, interests, or hobbies that you enjoy?
What is your overall grade point average?
A
AB+
B
BC+
C
C-
D+
D
Do you have a job or not? If so, where and how many hours a week?
What are your plans after high school?
Please tell us why you want to be in the Upward Bound Program.
Who has influenced you the most?
D-
F
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Parent /Family Information for Upward Bound Eligibility
Father ’s Name______________________________________ Email____________________
Place of Employment ___________________________________Phone ____________________
Mother’s Name_________________________________Email______________________________
Place of Employment__________________________________ Phone ____________________
Parent’s Phone:____________________________
Parent’s Email:________________________
Parent’s Mobile Phone:_______________________
Mother: Highest Level of Education completed (please circle one)
Elementary
High School
Bachelor’s Degree
Middle School
Master’s Degree
Two Year Degree
Father: Highest Level of Education completed (please circle one)
Elementary
High School
Bachelor’s Degree
Middle School
Master’s Degree
Two Year Degree
Parent’s current marital status:
___ Single
___ Married
___ Separated
___ Divorced
___ One parent deceased ___ Both parents deceased
Size of Family Unit
Income Level
1
$18,090
2
$24,360
3
$30,630
4
$36,900
5
$43,170
6
$49,440
7
$55,710
8
$61,980
For each additional
add $6,270
Income Verification Statement
My family’s *taxable income does ___ or does not ___ fall below the income guidelines in the table above
(Check the appropriate box).
Does the student qualify for free or reduced lunch? Yes _
or No _ _
Primary parent(s)/ guardian(s) of applicant: _______________________ Size of Family Unit___________
Parent Statement: The information I provided on this page is accurate to the best of my knowledge.
\
Parent(s)’/Guardian(s)’ Signature ___________________________________ Date: _______________________
*Taxable income- described as gross income or adjusted gross income minus any deductions/exemptions or other adjustments
that are allowed in that tax year.
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CONSENT TO PARTICIPATE
Central Lakes College’s UPWARD BOUND Program
I hereby certify that I give my consent for my son/daughter to participate in Central Lakes College’s
UPWARD BOUND Program. Neither Central Lakes College, or the Upward Bound Program, nor
any staff member will be held responsible for any injuries or obligations resulting from Upward
Bound program activities for my child.
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I understand the program covers the entire academic year and my son/daughter will attend a
meeting one Saturday a month. She/he will also take part in advising and tutoring sessions
with the Program Advisor(s) to support the student’s academic progress in high school.
I understand that my son/daughter may have the opportunity to attend the on-campus summer
session of the UPWARD BOUND Program for six weeks. Students will be on campus
Sunday night through Friday afternoon, except the July 4th holiday weekend, as determined
each year.
I understand that my son/daughter is a participant at the will of the UPWARD BOUND
Program and can be dismissed at the program’s discretion
I give my permission for him/her to take part in any off campus field trips that are sponsored
and supervised by UPWARD BOUND staff. I understand that the Program is not held liable.
I give my permission for Upward Bound staff members to transport the above student to and
from program activities if needed by bus or state vehicle. I understand that the program is not
held liable.
Parents/Guardians are expected to drop off and pick up their children or make arrangements
with others regarding transportation to and from Upward Bound events. I agree not to hold
Central Lakes College or Upward Bound TRIO Programs liable for any events that
potentially could occur before or after Program activities, during bus rides to and from
Program events, and for activities that could transpire before or after students are dropped off
or picked up on Program coordinated busses in various locations.
Permission is granted to Upward Bound staff to coordinate medical and/or counseling
services to the above named student, if deemed necessary by Upward Bound staff.
Permission is granted for Upward Bound staff to provide over the counter medications
(acetaminophen, Pepto-Bismol, ibuprofen, Dramamine, Sudafed, decongestants,
antihistamine, etc. for minor physical complaints. I understand the program is not held liable.
Permission is also granted at the Upward Bound Summer Program for the above student to
select elective classes that may involve recreational activities including supervised use of the
recreation center (rock climbing wall, swimming pool and gym) and supervised outdoor
recreational activity (canoe and kayak). (While staying at the motel on the field trip your
student will have the option of using the motel swimming pool (without supervision by a
trained lifeguard)). Staff will be present at poolside. Project staff does not assume liability
Permission is also granted for the above student to be part of social and classroom activities
when photographs and videotape are taken of students. Your signature gives Central Lakes
College Upward Bound the irrevocable right to use the image and/or voice of your student in
photo and video depictions of project activity (including composite or distorted
representations), waives all royalty fees for their use and manner of distribution, and waives
your right to inspect or approve of the final version(s) including any written copy that may be
created in connection there with.
Parent Signature: _______________________________
Date: ________________
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RELEASE OF INFORMATION
Central Lakes College Upward Bound
501 West College Drive, Brainerd, MN 56401
PHONE (218) 855-8011
FAX (218) 855-8267
GUARANTEE OF CONFIDENTIALITY OF INFORMATION
The personal information you give to UPWARD BOUND is sent to the Federal Government (Office of
Education). The information is protected by the Privacy Act. No one may see the information unless they
work with or for the UPWARD BOUND Program or are specifically authorized to see the information.
The information is necessary to determine if you are eligible to participate in the program and helps the
government to measure your success. The Office of Education has authority to gather information to help
make UPWARD BOUND a better program (20USC 1231a). If you do not give this information to the
UPWARD BOUND Program and the Office of Education, you cannot receive any benefits from the
program.
I hereby authorize the release of the following information to the UPWARD BOUND Program at
Central Lakes College:
A. Transcripts of grades from his/her junior high, middle school, and high school records
B. Standardized test scores
C. School instructor, counselor, psychologist, and social worker information relevant to the
student
D. School attendance records
E. Financial aid award letters
F. JTPA family financial information, AFDC and Social Security verification
G. Free/reduced lunch verification
H. Online access via the Internet to the student’s educational records via school website, First
Class or any other online delivery system
a. Student’s Username
b. Student’s Password
c. Upward Bound staff may be given Advisory status in the school if necessary to access
this information
d. In some target schools, one username and password for online access is given for an
entire family rather than each individual student. If necessary, I grant the UPWARD
BOUND PROGRAM access to the online family username and password log in
information. I understand this right to use would give the Program the ability to access
academic information on other potential students in our family unit who may not be in
the UPWARD BOUND Program.
All information is to be treated as confidential, in keeping to the Family Educational Rights and Privacy
Act. This release is to be considered valid for the period of time that my son/daughter remains a
participant or prior-year participant in the UPWARD BOUND Program. I fully understand the above
provision and hereby give my consent to have all pertinent data forwarded to the Central Lakes College’s
UPWARD BOUND Program for the aforementioned use.
________________________
Student Signature
_________
Date
_______________________________________
School Name
____________________________ ______
Parent/Guardian Signature
Date
___________________________
School Phone Number
______________________________________________________________________________
School Address
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Thank you for completing the application. Please return this to your school
Guidance Counselor or Principal if there is no Guidance Counselor.
Guidance Counselor / Principal Section:
Directions: Please fill in information to the best of your ability. If you have not received scores
in specific areas, simply write, “NA”. If you have questions, do not hesitate to call the Upward
Bound Assistant Director at 218.855.8011.
1. Student Grade:___________________________
2. Middle School cumulative grade point average (if student is a 9th Grader and up):_____________
3. Current Cumulative GPA at time of application _____________________________________
4. What is the student’s expected H.S. Grad. Date?________________________________
5. Please list additional standardized tests student has taken, if they have passed, and their
composite score (if not available on attached transcript; if on attached transcript, simply write “see
transcript”)
Additional Comments on this applicant for Upward Bound Staff:
____________________________________________________
____________________________________________________
____________________________________________________
In addition to this information, please attach a copy of the most
current transcript of the student that you have on file. Please include
any and all test score information on the transcript if possible.
Thank you for your cooperation and support of our program. Once completed,
Upward Bound staff will pick up this information. If you wish, you can also send it
to Upward Bound at:
Upward Bound
Central Lakes College
501 West College Drive
Brainerd, MN 56401
CLC is committed to a policy of nondiscrimination in employment and education opportunity. No person shall be discriminated against in the
terms and conditions of employment, personnel practices, or access to and participation in, programs, services, and activities with regard to
race, sex, color, creed, religion, age, national origin, disability, marital status, status with regard to public assistance, sexual orientation, or
membership or activity in a local commission as defined by law. This information is available in alternative format upon a 48-hour advance
request by contacting Disability Services at 800-933-0346, ext. 8175. Minnesota Relay Service: 800-627-3529 or 612-297-5353.
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